17 June 2021

The role of the coroner in New South Wales has existed for 234 years – longer, in fact, than the state itself. On 2 April 1787, Governor Arthur Phillip was granted the powers ‘to constitute and appoint justices of the peace, coroners, constables and other necessary officers’ for the new colony, just weeks before he embarked on the long journey to Australia aboard the First Fleet. Back then, the role of the coroner reflected British ideas about ‘sudden and unnatural deaths’ and how to investigate them.

Listen to Darrienne and Wilamina on 2SER here

What is a coroner? The modern definition of a coroner comes from the Coroner’s Act 2009. The Act empowers the coroner to assess and explain two things: the manner of a person’s death, and the cause of death. The manner of death classifies how an injury or disease process caused a person’s death and includes five categories: natural death, homicide, suicide, accident and undetermined. The cause of death is the specific injury or disease process that leads to a person’s death. The modern coroner also investigates the origins of fires and explosions that destroy or damage property within New South Wales, including big cases like the Luna Park Fire in the 1970s and the 1994 Eastern Seaboard Bushfires. Of course, it is not the coroner’s role to explain all deaths in the state; only those where the manner and cause of death has not been determined. Approximately 6000 deaths are reported to the office of the NSW state coroner each year, including 3000 occurring within the Sydney metropolitan area.

Commission to John Dight to act as a coroner in the Colony of New South Wales, 4 June 1828, Mitchell Library, State LIbrary of NSW (Safe 1/4b)

What was life like for early coroners? From their surroundings to their legal support, colonial coroners had a very different experience to the modern NSW state coroner. For over a hundred years, for example, the role of the coroner was supported by a mandatory jury of twelve. Naturally, finding twelve willing men from a population of a few thousand was often a difficult task for a coroner in colonial Sydney; this would have been practically impossible in rural areas. Early coroners weren’t working with a dedicated building or morgue, either, at least until the middle of the nineteenth century. They travelled widely and often, having to traverse large swathes of country to attend cases, with inquests held in local pubs or the rooms of the deceased. The position wasn’t as unpleasant as one might think – the colony was relatively small, meaning minimal contact with corpses, and the pay attractive. This unique role – and its pay cheque – attracted various interesting characters during the early days of the colony. Governor Macquarie selected John Lewin as the coroner for the town of Sydney and the surrounding County of Cumberland in 1810. Though he served in the role until his death in 1819, Lewin’s real passion was art – he was the colony’s first professional artist and published Australia’s first illustrated book, Birds of New Holland. Lewin’s successor, George Panton, wasn’t convinced of the position’s charms, resigning after just two months as coroner in November 1819 to take the role of Postmaster for New South Wales. Another colonial coroner, George Milner Slade, was especially colourful. Originally a paymaster for the 6th Battalion 60th Foot Regiment of the British Army, Slade was dismissed over a scandal in Jamaica involving misappropriated funds. Though inexperienced in most professions, the charming Slade managed to land on his feet, securing the office of coroner in 1821 to the tune of ninety pounds a year. Following a successful seven years as coroner, Slade opened several stores, went bankrupt, and still managed to secure further high-paying appointments in the New South Wales and Queensland colonies.

Morgues and courts The first formalised morgue in New South Wales was established in 1853, under experienced coroner John Ryan Brenan. Sick of the constant movement and uncertainty of his role, Brenan floated the idea of constructing a dedicated morgue near Cadman’s Cottage in Circular Quay.

Photographers and journalists outside the Coroner's Court, The Rocks c1930 by Sam Hood, Mitchell Library, State Library of NSW (PXE 789 (v.14), f30)

In the nineteenth and early twentieth centuries, morgues were more commonly (and crudely) known as dead houses. The Dead House at Circular Quay, which came to be known as the North Sydney Morgue, was designed by Colonial Architect William Weaver, and built by Thomas Coghlan. Both Weaver and Coghlan’s careers plummeted during the construction of the morgue, with Weaver resigning over financial issues and Coghlan prosecuted by the Crown for falsifying work hours. Despite this kerfuffle over work hours, the resultant Dead House was little more than ‘a room with a table on it’, as later noted by a disgruntled coroner, with space for only two bodies. If other cadavers were present, jury members would have to step over them; the only place for more than two bodies was on the floor. The stench of decomposing corpses was often unbearable for the twelve jury members, who preferred to attend inquests held in more appealing public houses such as the Observer Tavern nearby. The returns from interested patrons and thirsty jury members was an inviting prospect for local publicans.

The North Sydney Morgue remained in operation until the resumption of The Rocks at the turn of the twentieth century, when it was demolished alongside many other colonial buildings to rid the city of the threat of plague. The building was so dilapidated by 1901 that the Evening News referred to it as ‘the old tin shed at the Circular Quay’.

Meanwhile, the role of the coroner was changing. In 1861, an Act was passed ‘to empower Coroners to hold Inquests concerning fires’, as well as the power to grant bail to people charged with manslaughter as part of an inquest. The 1901 Coroners Act gave local coroners two intriguing extra powers; the legal power of a justice of the peace and the right to hold an inquest on a Sunday. This disturbance of the Sabbath was likely an unpopular choice with jurors.

A new combined Dead House and Coroner’s Court in the Rocks was completed in 1908 to the tune of £4235. Constructed from dark brick with a sandstone trim, the building was considered state of the art, with a glass-walled room available for viewing bodies and a dedicated laboratory. The court also provided separate waiting rooms for male and female witnesses.

The advent of science

As knowledge about the human body rapidly increased, so too did coronial practices. By the early 1900s, post-mortem examinations became a key part of how inquests were investigated. The chief medical officer of New South Wales at the time was Dr Arthur A Palmer. His vast experience earned him the nickname ‘The Post-Mortem King’. Science was moving too quickly for Sydney’s coronial system, however, and by the 1930s the modern facilities of the 1908 Coroner’s Court were considered outdated. Worse was to come – in 1936, the captain of the P&O cruise ship Strathaird complained that his passengers had a direct sight line to the post-mortem room, a rather appalling introduction to Sydney Harbour. Any plans to improve the court were put on hold during World War II, with additions and alterations finally made in 1947. This included the first instance of a refrigerated room for body storage.

New Coroner's Court - Architect's perspective 1967, Report of the Department of Public Works for the Year Ended 30 June, 1967 (Sydney: V.C.N. Blight, 1967), p. 46, Mitchell Library, State Library of NSW (Q620.09/N)

To better serve the growing Sydney community, and the growing complexities of the legal and forensic world, a new facility was planned on Parramatta Road. Constructed on the old site of a coach-maker’s workshop, the two-storey Glebe Coroner’s Court was officially opened in 1971. The courtrooms, counselling rooms, extra laboratories and offices were located in the top ‘public’ section while the bottom section was the turf of the forensic pathologists, technicians and lab assistants who cared for the deceased. Though all precautions were taken to separate the two floors and their various functions, occasionally the two worlds collided with memorable results. In July 1973, the courtrooms had to be evacuated due to a strong smell coming from the morgue below, after an air-conditioning malfunction caused foul air to be diverted into the courtroom. The Glebe Coroner’s Court was the centre of coronial power in New South Wales from 1971 to 2018, seeing famous cases including the Granville Rail Disaster in the 1970s, the Strathfield massacre of 1991 and the 1995 death of Anna Wood. In 2018, the court was moved to a multimillion dollar complex in Lidcombe.

Read Darrienne's entry on the Glebe Coroner's Court here and click through the links to further explore the history of the role of the coroner in Sydney.

Darrienne Wyndham is a heritage consultant at Artefact Heritage Services and has recently written a series of essays on the role of the coroner in New South Wales for the Dictionary of Sydney, which were published with support from Artefact & Health Services. She specialises in the interpretation of historic sites, buildings and railway stations. Her research has spanned a wide range of time periods and locations across Sydney, from nineteenth century roads in the eastern suburbs to World War II internment camps in Moorebank.

Thanks Darrienne! For more Dictionary of Sydney, listen to the podcast with Darrienne & Wilamina here, and tune in to 2SER Breakfast on 107.3 every Wednesday morning to hear more stories from the Dictionary of Sydney.